Medication Summary

Use RSI when intubating to minimize rises in ICP and catecholamine release. Etomidate, when used as RSI sedating agent, maintains blood pressure, lowers ICP and brain metabolism, and has rapid onset and brief duration. Thiopental is not recommended because of its predictable effect in lowering blood pressure, the leading cause of secondary brain injury. Mannitol osmotically reduces ICP and improves blood flow. Phenytoin provides prophylaxis against early posttraumatic seizure. Once the patient has received adequate fluids, pressors such as norepinephrine can be used to maintain MAP >90 mm Hg.

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Osmotic diuretic

Class Summary

Osmotically reduces brain edema and ICP and reduces blood viscosity, improving cerebral blood flow and oxygen delivery. Prior to ICP monitoring, use only for signs of herniation or progressive neurological deterioration. Hypovolemia should be avoided by replacing fluids (urine monitoring with placement of a bladder catheter is essential). Intermittent boluses may be more effective than continuous infusion.

Right temporal epidural hematoma with midline shift. Patient should be taken immediately to the operating room for neurosurgery. This may require emergent transport to a trauma center or other facility with a neurosurgeon available.

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine